DIEP flap perfusion assessment using microdialysis versus Doppler ultrasonography: A comparative study.

BACKGROUND: The increasing number of buried free-tissue transfer procedures and the need for an objective method to evaluate vascular complications of free flaps has led to the development of new technologies. Microdialysis has been used to monitor free flaps using interstitial biological markers. Previous uses mainly focused on muscular flaps. Our aim is to compare external Doppler ultrasonography (EDU) evaluation versus microdialysis in the early follow-up of adipocutaneous flaps, and propose an efficient postoperative monitoring protocol. METHODS: We retrospectively assessed 68 consecutive DIEP flaps (50 patients) performed between January 2019 and March 2021. All flaps received standardized post-operative monitoring using clinical signs, EDU and microdialysis. Glucose and lactate concentrations were assessed using glucose <1 mmol/L and lactate >6 mmol/L as ischemic trend thresholds. We calculated Glucose/Lactate ratio as a new parameter for the assessment of flap viability. RESULTS: Among all the 68 flaps, two flaps returned to the operative theater when a combination of unsatisfactory microdialysis values and clinical/EDU signs identified vascular impairment; only one developed total flap necrosis. Reoperation rate was 2.94% with an overall flap success rate of 98.53%. External Doppler ultrasonography had 100% sensitivity and 82% specificity, while microdialysis had 100% sensitivity and 100% specificity. CONCLUSIONS: Microdialysis values proved flap viability sooner than external Doppler ultrasonography, making it an excellent tool for post-operative monitoring. With the appropriate thresholds for glucose and lactate concentrations, and glucose/lactate ratio used as a new parameter, it can help potentially avoiding unnecessary re-explorations, and reducing flap ischemia times.

Marking the nipple-areola complex in mastopexy and reduction mammoplasty: a geometrical method.

Mastopexy and reduction mammoplasty are well-established procedures used to address ptotic and hypertrophic breasts. A variety of methods have been described in the literature for managing the three main aspects of these procedures: skin excess, parenchyma, and the nipple-areola complex (NAC). Among these techniques, several have specifically addressed the markings of the NAC in procedures involving a preoperatively established NAC position. While many of these have proven effective over time, the literature lacks standardized and reproducible methods. In this paper, we introduce, step-by-step, a novel approach based on geometrical principles to address this limitation. This method involves the simple process of drawing two hemi circumferences on the vertical limbs of the skin resection pattern, which are commonly marked using the Bisemberg maneuver or similar techniques. The method we introduce is adaptable to virtually all NAC pedicles. Furthermore, as exemplified in the accompanying video, it can be incorporated to most skin resection patterns with a preoperatively defined NAC position. The clinical application, as evidenced in the case reported, appears to be promising. Although it has some limitations, this procedure shows the potential to reduce inaccuracy by minimizing variability factors. As a result, even inexperienced surgeons can achieve precise markings.